A Portrait of a Mentally Ill Person

This is a vignette I wrote as a practice exercise for the clinicians under my supervision. The point of the exercise was to read the vignette and render a provisional diagnosis for RJ. RJ and all the information about him in the vignette is made up. None of it is real, but it reflects some of the common presentations we therapists encounter as we work with patients.

RJ is a 35 year-old, single, Asian male. He lives with his parents who immigrated to the US from Japan when he was only 3 years old. His mother came to RJ’s first session with him. RJ had called the previous week stating he was depressed and wanted an evaluation. His mother was reluctant to share information about RJ and seemed to minimize his symptoms. RJ told the therapist that he had been depressed and anxious as long as he could remember. He stated that he worries about a lot of things. He feels guilty that he still lives at home. He has been unable to work due to symptoms. He reports feeling hopeless about the future and worries incessantly about disappointing his parents. He worries about not finding a spouse. He worries so much that he is unable to go to sleep, due to his mind racing. RJ recognized that most of his worries and “what if” scenarios had a very low chance of actually occurring. After his mother left the room, RJ disclosed to the therapist that the reason he finally decided to seek treatment was that he had been having hallucinations. He also felt that his parents were deeply disappointed in him and talked negatively about him when he wasn’t around. He has been feeling that the neighbors have been criticizing him too because he did not go to a job and still lived at home. He had become obsessed with what others thought about him. The hallucinations were command hallucinations at times, with a voice telling him to harm himself. He had not told his parents about the hallucinations. This was the first time he had ever experienced hallucinations. RJ also confided to the therapist that he had been chronically suicidal since he was a teenager. The therapist noted that RJ’s movement and speech were labored and his posture was slouched. It took RJ much more time to answer the therapist’s questions than the average person. Also, recently his parents had seen him walking around outside at all hours of the night… usually talking, but no one was there. In the mornings, RJ did not remember doing so. RJ had shared his symptoms with his family doctor who prescribed 10 mgs of Ambien at bedtime and 2 mgs of Klonopin three times per day. He also prescribed Cymbalta for the depression and Seroquel, for the hallucinations. RJ has numerous physical complaints as well. He has chronic diarrhea and feels nauseated in the mornings. He also complains of severe headaches and severe lack of energy. RJ was most concerned about the hallucinations (He worried he was going “crazy”.). He was also very concerned that the therapist not share his hallucinations with his family—He didn’t want to “dishonor” them. Finally, RJ doesn’t drive much because he is afraid he will hit someone. When he does drive, he feels he must read the 10 commandments 3 times first. He also feels he must drive the speed limit exactly as posted.